MEDICAL ETHICS ANDETHICAL ISSUES IN PUBLIC HEALTH By- Dr. Dharmendra Gahwai (PG student)Guided by – Dr. Y.D. Badgaiyan Prof. and Head Deptt. Of Community Medicine CIMS, Bilaspur(C.G.)
BACKGROUND From the time immemorial doctors have been held in high esteem by the society in different parts of the world. Medical ethics have existed ever since the practice of medicine and references are available even in ancient civilization.
The society consider the doctor as friend- philosopher and guide, which bestows enormous responsibility upon the doctor. This responsibility is quite apart from technical skills and is more to do with qualities of human understanding. Medical Ethics is all about this responsibility.
ETHICS Dictionary meaning – “System of moral principle, rules and conduct.” Origin of this word is from ETHOS which mean ‘Character’. Ethics is defined as “the ability to distinguish between right and wrong and to act accordingly.”
“Ethics is the activity of man directed to secure the inner perfection of his own personality.” - Albert Schweitzer.
MEDICAL ETHICS Medical Ethics is described as code of behavior accepted voluntarily within the profession as opposed to statutes and regulations imposed by official legislation.
The oldest code of medical ethics is Hippocratic oath . Though now, some 25 centuries old , its basic tenets remain as valid as ever.
In view of changing world scenario, the Oath was restated into the Declaration of Geneva by the World Medical Association after the second World War. The Medical Council of India gives a copy of declaration to concerned applicant for registration who shall read and agree to abide by same.
DECLARATION1. I solemnly pledge myself to consecrate my life in service of humanity.2.Even under threat, I will not use my medical knowledge contrary to the laws of humanity.3.I will maintain utmost respect for human life from the time of conception.4.I will not permit considerations of religion, nationality, race , party politics or social standing to intervene between my duty and my patient.5. I will practice my profession with conscience and dignity.
6. The health of my patient will be my first consideration.7. I will respect the secrets, which are confined in me.8. I will give to my teacher the respect and gratitude which is their due.9. I will maintain by all means of my power , the honour and noble traditions of medical profession.10. My colleagues will be my brother. I make this promises solemnly, freely and upon my honour.
PRINCIPLES OF ETHICS 1.Beneficence. 2.Non-maleficence. 3.Autonomy. 4.Justice or equity.
PRINCIPLE OF BENEFICENCE Beneficence refers to the tradition of acting always in the patient’s best interest to maximise benefits and minimise harm.
PRINCIPLE OF NON-MALEFICENCE This principle ensures that treatment or research not ought to produce any harm to the patient. By any mean of - Negligence. Misconduct.
PRINCIPLE OF AUTONOMYRespect for an individual’s autonomy or ability tomake decisions for him/herself includes- respect for their privacy and confidentiality need to provide sufficient information for them to make informed choices truth telling and protection of persons with diminished or impaired autonomy.
PRINCIPLE OF JUSTICE or EQUITY Justice refers to the need to treat all people equally and fairly. Society uses a variety of factors as a criteria for distributive justice, including : to each person an equal share to each person according to need to each person according to effort to each person according to contribution to each person according to merit to each person according to free-market exchanges
We should strive to provide some decent minimum level of health care for all citizens, regardless of ability to pay .
In 1960 medical ethics were predominantly associated with Non-maleficence i.e. non harming the patient. And the principle of doing good (beneficence) has been unquestionably recognizes as being important.
In 1970’s, the principle of respect for autonomy was added and concerned with human dignity, freedom and respect for the fundamental rights of individuals.
Justice (equity) is a concept of fairness and impartiality. It not only means equal share in the distribution of health care (equality) But, more importantly priority should be given to those who are in need , in proportion to their need (equity).
For a Public Health Specialistthe emphasis is on the greatergood of larger numbers ofpeople and the principle ofjustice plays an important role.
AIDS Today , no nation of the earth can escape the consequences of AIDS. The incurable nature of disease and the venereal and blood transmissible nature of HIV acquisition give rise to peculiar dilemma and difficulties.
The ethical issues involved withAIDS are –1. The treatment of AIDS cases : - The doctor is not entitled to refuse to treat a patient with AIDS or HIV positive.2. Disclosure to other health professionals: - confidentiality vs prevention of spread of infection.3. Serological screening: - it is unethical to take up serological testing without consent. - however, there is no other way to identify HIV carriers.
4. Blood donations:• Whether destroying the infected blood is enough ?• Should not the donor be informed about his/her status regarding HIV positivity ?• Prevention of spread of infection to spouse and offspring.• So , should not the spouse and family members be informed about HIV-positive status of patient?
5. Individual vs Social responsibilities:• It seems reasonable in the interest of an individual in particular and the society in general to let them to be informed.• But, Questions are , - how the issue should be communicated to the person’s family (spouse) and friends, - whether patient consent is required for it or not; - all these need a wider consideration with danger to others in society.
Recently in a landmark case of Dr. Yepthomi vs. Apollo Hospital , Chennai, the Hon’ble Supreme Court has ruled that - “prospective spouses have a right to know about HIV status of their prospective counterparts and disclosure by concerned hospital cannot be a breech of confidentiality.”
ABORTION Medical Termination of Pregnancy(MTP) Act 1972 , specifies- the conditions, under which pregnancy can be terminated.- Persons, who can perform the termination and- Places, where such a procedure can be performed.
Ethical issues in abortion are-• The view that fetus has the same right to life as that of other individual.• The modern Geneva convention code says - “ I will maintain the utmost respect for human life from the time of conception.”• So, the debate is in between - “Murder of an innocent” vs “the Right of a women”.
UTILITARIANISM (rule-utilitarianism ) (Middle course between the two views)THERAPEUTIC ABORTIONThe arguments in favor are-1. The health of mother is more important then fetus.2. If, the expected quality of fetus life is so poor so, it is better not experience it.3. When well being of society is improved by permitting abortion in certain conditions.
1. Abortion should be performed only as a therapeutic measure .2. A decision to terminate the pregnancy should normally be approved in writing by at-least two doctors .
EUTHANASIA Under the present law, voluntary euthanasia would be regarded as suicide in the patient who consents and murder in the doctor who administers .
Two ethical components are – AIM and AUTONOMY The fundamental aim of medical care is beneficence , however , relief of pain and suffering by putting an end to a patient – is a misery , could be considered beneficence. But, killing can hardly be constructed as no harm (non-maleficence).
Autonomy , affects doctors , patient and relatives. As we know, a patient has right to refuse treatment , Does this autonomy extend to asking for euthanasia ?
STERLIZATION In view of the fact that sterilization drives are of public importance in countries where there is population explosion, So, the social and ethical issues may be overlooked. (as in case of Emergency period in INDIA)
In some states where the statutory law provides for therapeutic sterilization but does not provide for non therapeutic one then physicians and hospitals perform sterilizations for purely social or economic reasons are illegal and therefore , it is criminal.
While ethical issues in medical researchand practices are discussed anddebated but ethics in public health andpublic health policies is rarely discussedand given very little importance.
CASE STUDIES1. Immunization for Pertussis.2. Fluoridation of water.3. Rights of patient with contagious venereal disease.4. Universal iodization of salt.
Immunization for Pertussis• Since 1933, there have been reports of neurological complications after immunization of Pertussis.• The inconclusive nature of complication resulted debate in media particularly in Britain.• The rate of immunization halved from >78.5% in 1971 to 37% in 1974.• An epidemic of pertusis was reported and under Vaccine Damage Payment Act £ 10000 each has been paid over 500 children.
In this case beneficence was observed that the immunization protect the children against disease . But , due to neurological side effects the principles of non-maleficence was not respected. At individual level parents can exercise freedom not to immunize.(autonomy) however , such decision could fail the immunization programme.
In 1981 , a case control study named National Childhood Encephalopathy Study (NCES) was initiated in England to assess the association between serious neurological illness and pertussis vaccine. They did not report any significant association between encephalopathy and pertussis vaccine.
In 1988 ,the famous Vaccine Court Trial vindicated the use of the vaccine and observed that is far from causing encephalopathy.
Fluoridation of water From the 1930’s it was noted that there was an inverse relationship between the levels of fluoride in drinking water and occurrence of dental caries. This suggested a preventive measures of policy of adding fluoride to water with low fluoride level.
There were objections on the grounds of undesirable side effects such as development of Down Syndrome and Cancer in area of fluoridation of water. The second objection was related to it being a compulsory medication.
Non-maleficence : objection due to suspicion of excess fluoride leads to cancer is justifiable with ethical principle of non-maleficence. However, it was not based on scientific facts. Autonomy : the second objection was with compulsory medication (fluoridation) . This illustrates conflicts between the principle of Autonomy with the positive community effects of fluoridation (Beneficence).
However, in Britain (1985) , the Report of the Working Committee on Fluoridation of Water and Cancer found no evidence of association of fluoridation of water and development of Cancer.
Contagious Venereal Disease Dr. Yepthomi a doctor from Nagaland filed a petition seeking compensation from the Apollo Hospital Chennai , which had found that he was HIV-positive and disclosed it to would be Bride’s family. The marriage was immediately called off.
This case illustrates the conflict between respect for autonomy and principle of beneficence. In such a case, where there is a clash of two fundamental rights, namely the patient’s right to confidentiality and the bride’s right to lead to healthy life ,the right of public interest would be enforced through the court.
The Supreme Court of India has given a judgment on right to marry of a patient with contagious venereal disease , that “ so long as a person is not cured of the disease , his right to marry is suspended.” AND The Hon’ble Supreme Court has ruled that “prospective spouses have a right to know about HIV status of their prospective counterparts and disclosure by concerned hospital cannot be a breech of confidentiality.”
Universal Iodization of Salt• On Sept. 2000 , the Govt of India lifted the ban on the sale of non-iodized salt which was enforced in Nov 1997.• The reason given was that food consumption is a matter of individual choice (Autonomy) and cannot be forced upon people.
Universal Iodization of Salt1. Beneficence : Fortification of salt with iodine can be considered as a vaccine for proper growth and development of child.2. Non-maleficence : No untoward effect of excess iodine consumption.3. Justice(equity) : Priorities should be given to those in need.(in iodine deficient area).4. Autonomy : Universal salt iodization is a compulsory medication and therefore , a violation of individual autonomy.
Lack of any maleficence and proof of beneficence clearly vindicate the intervention of salt iodization . The conflict seems to be between equity and autonomy. The best option is obviously to have a salt iodization programme only in iodine deficient area.
Respect for autonomy and equity (justice) is more subjective. The decision is often taken by the court or by scientist in given cases. Both of them are not right forum for decision regarding the public health policies.
Three principles must be followed in arriving at any decision on ethical issues in public health. The process should ensure that the decision would be : 1. Taken by representative body. 2. An informed consent. 3.By consensus.
INDIAN ACTS/ORDERS RELATED TO HEALTH Epidemic Diseases Act – 1897 Red Cross Society (Allocation of Property Act) – 1936 Drugs and Cosmetics Act – 1940 Indian Nursing Council Act – 1947 Dentists Act – 1948 Pharmacy Act – 1948 Employees State Insurance Act – 1948 Medical Council of India Act – 1956, amended 2002 Drugs and Magic Remedies Act (Objectionable advertisements), 1954 Prevention of Cruelty to Animals Act – 1960 Children Act – 1960 Maternity Benefit Act – 1961 Central Council for Indian Medicine Act – 1970
INDIAN ACTS/ORDERS RELATED TO HEALTH Medical Termination of Pregnancy Act – 1971 Consumer Protection Act – 1986 Environment Protection Act – 1986 Mental Health Act – 1987 being amended Rehabilitation Council of India Act - 1992 Pre-natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act -1994, amended 2002 Organ Transplantation Act – 1994 Persons with Disabilities (Equal Opportunity, Protection of Rights and Full Participation Act, 1995 Pre-conception and Prenatal Diagnostic Techniques (Prohibition of sex selection) Act - 2003 Guidelines for Exchange of Biological Material (MOH order, 1997) Right to Information Act - 2005
• Ethical decisions are rarely simple.• No more rules and laws, but what we needed now is clear thinking about the key issues and conflicts of interests.
• While the decision is important , the process of arriving at that decision is of paramount importance.• The public and government will have to make informed choices .
The World Health Organization says public health as “an art and a science”. The art of the public health is to persuade the public and government to adopt the policies that are derived from scientific data.
It is time that we moved from ad-hoc approach to a more rational scientific approach in solving ethical issue in public health policy.